RN Nurse Case Management Lead Analyst - Work from Home, Anywhere, USA
Nurse Case Management Lead Analyst-Nurse Clinician Accredo
Job Description Summary
The Nurse Clinician RN is responsible for reviewing escalated clinical criteria reviews for providers, members and patient client advocates within the Prior Authorization/Utilization Management department. Identify and track trends for analytics reporting to ensure clinical criteria program integrity. Maintain a professional and ethical behavior at all times as outlined by the Nurse Practice Act and applicable company policies.
Ideal candidate must be available to work CST, MST or PST time zones.
JOB DUTIES:
Conduct criteria reviews for commercial payers, Medicare, and Medicaid
Provide prior authorization assistance, and denial appeal assistance
Prepare and write medical necessity appeal letters for claim denials for commercial and government payers.
Support all aspects of Patient Access and Revenue Cycle Management (PARCM), including clearance and reimbursement for multiple Therapeutic Resource Centers.
QUALIFICATIONS
Active, unencumbered Registered Nurse (RN) license in state of residency.
High School Diploma or GED, plus 8+ years of relevant RN experience; or
5+ years of relevant RN experience with an ASN degree; or
2+ years of relevant RN experience with a BSN degree
Case management experience preferred
5+ years of experience is preferred in prior authorization or utilization review and appeals
Demonstrated proficiency with Microsoft Office software; basic database navigation
Ability to multitask in both PC/Phone related tasks
Ability to build strong working relationships with colleagues and customers
Strong time management skills and the ability to prioritize work and meet deadlines
Excellent verbal and written communication skills
Ability to work Monday-Friday, 8am-5pm, Eastern time
Adequate home internet access will be required in this role
TECHNICAL SKILLS:.
Experience with Cover My Meds Tool
Experience with Myndshft Tool
5+ years of experience is preferred in prior authorization or utilization review and appeals
Case Management experience a plus
Demonstrated proficiency with Microsoft Office software; basic database navigation
Ability to multitask in both PC/Phone related tasks
SOFT SKILLS:.
Ability to build strong working relationships with colleagues and customers
Strong time management skills and the ability to prioritize work and meet deadlines
Excellent verbal and written communication skills
Ability to work Monday-Friday, 8am-5pm, Eastern time
Adequate home internet access will be required in this role
COMPETENCIES:
Communicates Effectively
Collaborates
Customer Focus
Decision Quality
Nimble Learning
If you will be working at home occasionally or permanently, the internet connection must be obtained through a cable broadband or fiber optic internet service provider with speeds of at least 10Mbps download/5Mbps upload.
For this position, we anticipate offering an annual salary of 76,600 - 127,600 USD / yearly, depending on relevant factors, including experience and geographic location.
This role is also anticipated to be eligible to participate in an annual bonus plan.
We want you to be healthy, balanced, and feel secure. Thats why youll enjoy a comprehensive range of benefits, with a focus on supporting your whole health. Starting on day one of your employment, youll be offered several health-related benefits including medical, vision, dental, and well-being and behavioral health programs. We also offer 401(k) with company match, company paid life insurance, tuition reimbursement, a minimum of 18 days of paid time off per year and paid holidays. For more details on our employee benefits programs, visit Life at Cigna Group.
About Evernorth Health Services
Evernorth Health Services, a division of The Cigna Group, creates pharmacy, care and benefit solutions to improve health and increase vitality. We relentlessly innovate to make the prediction, prevention and treatment of illness and disease more accessible to millions of people. Join us in driving growth and improving lives.
Qualified applicants will be considered without regard to race, color, age, disability, sex, childbirth (including pregnancy) or related medical conditions including but not limited to lactation, sexual orientation, gender identity or expression, veteran or military status, religion, national origin, ancestry, marital or familial status, genetic information, status with regard to public assistance, citizenship status or any other characteristic protected by applicable equal employment opportunity laws.
If you require reasonable accommodation in completing the online application process, please email: [email protected] for support. Do not email [email protected] for an update on your application or to provide your resume as you will not receive a response.
The Cigna Group has a tobacco-free policy and reserves the right not to hire tobacco/nicotine users in states where that is legally permissible. Candidates in such states who use tobacco/nicotine will not be considered for employment unless they enter a qualifying smoking cessation program prior to the start of their employment. These states include: Alabama, Alaska, Arizona, Arkansas, Delaware, Florida, Georgia, Hawaii, Idaho, Iowa, Kansas, Maryland, Massachusetts, Michigan, Nebraska, Ohio, Pennsylvania, Texas, Utah, Vermont, and Washington State.
Qualified applicants with criminal histories will be considered for employment in a manner consistent with all federal, state and local ordinances.
Apply Now
Job Description Summary
The Nurse Clinician RN is responsible for reviewing escalated clinical criteria reviews for providers, members and patient client advocates within the Prior Authorization/Utilization Management department. Identify and track trends for analytics reporting to ensure clinical criteria program integrity. Maintain a professional and ethical behavior at all times as outlined by the Nurse Practice Act and applicable company policies.
Ideal candidate must be available to work CST, MST or PST time zones.
JOB DUTIES:
Conduct criteria reviews for commercial payers, Medicare, and Medicaid
Provide prior authorization assistance, and denial appeal assistance
Prepare and write medical necessity appeal letters for claim denials for commercial and government payers.
Support all aspects of Patient Access and Revenue Cycle Management (PARCM), including clearance and reimbursement for multiple Therapeutic Resource Centers.
QUALIFICATIONS
Active, unencumbered Registered Nurse (RN) license in state of residency.
High School Diploma or GED, plus 8+ years of relevant RN experience; or
5+ years of relevant RN experience with an ASN degree; or
2+ years of relevant RN experience with a BSN degree
Case management experience preferred
5+ years of experience is preferred in prior authorization or utilization review and appeals
Demonstrated proficiency with Microsoft Office software; basic database navigation
Ability to multitask in both PC/Phone related tasks
Ability to build strong working relationships with colleagues and customers
Strong time management skills and the ability to prioritize work and meet deadlines
Excellent verbal and written communication skills
Ability to work Monday-Friday, 8am-5pm, Eastern time
Adequate home internet access will be required in this role
TECHNICAL SKILLS:.
Experience with Cover My Meds Tool
Experience with Myndshft Tool
5+ years of experience is preferred in prior authorization or utilization review and appeals
Case Management experience a plus
Demonstrated proficiency with Microsoft Office software; basic database navigation
Ability to multitask in both PC/Phone related tasks
SOFT SKILLS:.
Ability to build strong working relationships with colleagues and customers
Strong time management skills and the ability to prioritize work and meet deadlines
Excellent verbal and written communication skills
Ability to work Monday-Friday, 8am-5pm, Eastern time
Adequate home internet access will be required in this role
COMPETENCIES:
Communicates Effectively
Collaborates
Customer Focus
Decision Quality
Nimble Learning
If you will be working at home occasionally or permanently, the internet connection must be obtained through a cable broadband or fiber optic internet service provider with speeds of at least 10Mbps download/5Mbps upload.
For this position, we anticipate offering an annual salary of 76,600 - 127,600 USD / yearly, depending on relevant factors, including experience and geographic location.
This role is also anticipated to be eligible to participate in an annual bonus plan.
We want you to be healthy, balanced, and feel secure. Thats why youll enjoy a comprehensive range of benefits, with a focus on supporting your whole health. Starting on day one of your employment, youll be offered several health-related benefits including medical, vision, dental, and well-being and behavioral health programs. We also offer 401(k) with company match, company paid life insurance, tuition reimbursement, a minimum of 18 days of paid time off per year and paid holidays. For more details on our employee benefits programs, visit Life at Cigna Group.
About Evernorth Health Services
Evernorth Health Services, a division of The Cigna Group, creates pharmacy, care and benefit solutions to improve health and increase vitality. We relentlessly innovate to make the prediction, prevention and treatment of illness and disease more accessible to millions of people. Join us in driving growth and improving lives.
Qualified applicants will be considered without regard to race, color, age, disability, sex, childbirth (including pregnancy) or related medical conditions including but not limited to lactation, sexual orientation, gender identity or expression, veteran or military status, religion, national origin, ancestry, marital or familial status, genetic information, status with regard to public assistance, citizenship status or any other characteristic protected by applicable equal employment opportunity laws.
If you require reasonable accommodation in completing the online application process, please email: [email protected] for support. Do not email [email protected] for an update on your application or to provide your resume as you will not receive a response.
The Cigna Group has a tobacco-free policy and reserves the right not to hire tobacco/nicotine users in states where that is legally permissible. Candidates in such states who use tobacco/nicotine will not be considered for employment unless they enter a qualifying smoking cessation program prior to the start of their employment. These states include: Alabama, Alaska, Arizona, Arkansas, Delaware, Florida, Georgia, Hawaii, Idaho, Iowa, Kansas, Maryland, Massachusetts, Michigan, Nebraska, Ohio, Pennsylvania, Texas, Utah, Vermont, and Washington State.
Qualified applicants with criminal histories will be considered for employment in a manner consistent with all federal, state and local ordinances.
Apply Now